| Authorization for [insert name of physician or clinic] to Use or Disclose My Health Information
Patient name: ________________________________ Date of
birth:______________________
Previous name: _____________________________________
I. My Authorization
You may use or disclose the following health care information (check all that apply):
All my health information maintained by [insert name of physician or clinic]
My health information relating to the following treatment or condition:
_______________________
My health information for the date(s):_____________________________________
Other:___________________________________________________
You may disclose this health information to:
Name (or title) and organization_____________________________________________________
Address: ____________________________City _______________State _________Zip_______
Reason(s) for this authorization (check all that apply):
|
at my request |
check here only when [insert physician or clinic name] requests the authorization for marketing
purposes
check here only when [insert physician or clinic name] will get something of value for providing health information for marketing purposes |
other (specify)_____________________
__________________________________
__________________________________ |
|
This authorization ends: |
on (date) __________________ |
|
when the following event occurs _________________________ |
II. My Rights
I understand I do not have to sign this authorization in order to get health care benefits (treatment, payment or enrollment). However, I do have to sign an authorization form:
- To take part in a research study.
or
- To receive health care when the purpose is to create health information for a third party.
I may revoke this authorization in writing. If I did, it would not affect any actions already taken by [insert physician or clinic name] based upon this authorization. I may not be able to revoke this authorization if its purpose was to obtain insurance. Two ways to revoke this authorization are:
- Fill out a revocation form. The form is available from the office.
or
- Write a letter to the office.
Once the office discloses health information, the person or organization that receives it may re-disclose it. Privacy laws may no longer protect it.
________________________________
Patient or legally authorized individual signature |
_______________ ________________
Date
Time |
________________________________
Printed Name if signed on behalf of the patient |
________________________________________
Relationship (parent, legal guardian, personal representative, etc.) |
|